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Major medical schemes and other industry bodies have welcomed the release of the National Health Insurance (NHI) bill as a step towards universal health coverage.

Health Minister Aaron Motsoaledi on Thursday gazetted the NHI bill and the Medical Schemes Amendment bill for public comment, for a period of three months.

NHI is the state’s plan for comprehensive health services for all South African citizens and long-term residents.

According to the NHI White Paper from 2017, its goal is to create a "single, publicly owned and administered strategic purchaser" that will buy healthcare services for all South Africans with accredited public and private providers.

The implementation of NHI is not going to be a once-off event, but will rather take a phased-in approach, said Motsoaledi. The state has set aside five years from 2017 to 2022 for the development of NHI legislation and amendments to other legislation.

The Board of Healthcare Funders of Southern Africa (BHF), which represents 45 medical aid schemes, administrators and managed care organisations in South Africa, supports the new NHI bill's objective.

"As an industry representative body, we support the intention and action aimed at ensuring that the greater population of the country receives quality healthcare," said Dr Ali Hamdulay, chairperson of the BHF of Southern Africa.

Hamdulay said that universal life coverage should be made available to the South African population, and not just those covered in private healthcare.

He also stressed the importance of the private sector working together with government. "It’s now time for action and close collaboration, and we are going in on this together," he said.

Sipho Kabane, acting CEO of the Council of Medical Aid Schemes, said there was a general consensus of acceptance among medical aid schemes.

"It is no doubt that the bill will have a financial impact on companies, but most medical schemes understand the need for universal healthcare.

"But you also find those who are unhappy about the concept," he told Fin24.

Some companies had expressed concern that if the system were introduced too soon, it might hurt their financial viability. But NHI will be gradually phased in, and that would not cause shocks to the market and their financial accounts. "The good thing about the NHI is that it would enforce social solidarity, where the rich would subsidise the poor, and the young will subsidise the old," Kabane said.

Governance issues

Among the proposals made for the Medical Schemes Amendment bill relates to the governance of medical schemes, which was raised by the council. "The council has been vocal about the level of poor governance that exist in some schemes, where the boards take poor decisions that eventually impact on the consumers," said Kabane.

It seeks to introduce a minimum educational requirement and expertise to be a member of a board of trustees or a CEO of a medical aid scheme.

Motsoaledi noted that there were some union members which sit on boards, and he is not opposed to that. The union should appoint a person with the required skills and qualifications to represent their interests.

Kabane added that the new law would enforce accountability among companies and improve the effectiveness of the council.

Ahead of Motsoaledi’s press briefing on Thursday, Dr Rajesh Patel, who is on the BHF board, also shared views with Fin24 that NHI would instill accountability in the statement. Tragedies like that of Life Esidimeni had happened due to a lack of accountability and weaknesses in governance.

Medical schemes weigh in

In a statement, Dr Jonathan Broomberg, CEO of Discovery Health, said the NHI bill and establishment of the NHI Fund were a "big step" towards achieving universal healthcare for all South Africans.

"The inequalities in access to quality healthcare services for all South Africans are a major concern for all South Africans. Based on our initial review of the NHI bill, we are supportive of the general approach taken, including the fact that medical schemes will continue to operate alongside the NHI," said Broomberg.

"We are also supportive of the various governance and advisory mechanisms established," he added.

Broomberg was also supportive of the NHI Fund focusing on priority projects for vulnerable groups "where the need is the greatest", as well as the focus on critical health priorities such as oncology, high-risk pregnancies and investment in critical preventative measures through the school screening programme.

Broomberg said that more views on the Medical Schemes Amendment bill would be given in due time, as there are complex issues which need to be studied.

Damian McHugh, head of Momentum Health Sales and Marketing, is optimistic that the private healthcare system and NHI can operate together.

"Both systems should be able to work together and support each other in delivering a better, more sustainable health care solution for all South Africans. We believe if public and private systems work together we will have a superior solution."

Dr Guni Goolub, principal officer of the Government Employees Medical Scheme (GEMS) told Fin24 that there may no be immediate business impact, as NHI will be implemented in phases.

"Once the NHI is fully implemented, which will be from 2022 onwards, we will then have to find ways [...] to reposition ourselves to complement its services," said Goolub.

"I believe that medical aid schemes will still have a role to play, even when the NHI comes into effect. I believe that they would play a complementary role, like offering cover for medical services that won’t be covered by the health insurance."

Jeremy Yatt, CEO of Fedhealth, told Fin24 that Fedhealth was fully behind the concept of universal healthcare. "There is absolutely no reason why we would not want more of our citizens to have access quality and affordable healthcare."

Yatt, however, said that affordability issues were out of the control of private healthcare practitioners, as these were requirements set out in legislation.

"We support universal healthcare, but we are not sure that the NHI is going to accomplish that objective."

Yatt expects a lot of pushback on the bill, from doctors and even brokers – given that among the proposals of the medical schemes bill is to abolish the use of brokers. Doctors may also take issue with being told how much they should charge for services, Yatt explained. This could end up in court battles costing the department of health millions, and elongating the time frame to implement NHI.

Yatt argued that the solution was not to curtail how much private sector healthcare providers can charge, but rather to address how to access healthcare benefits. Yatt said it was important to have consultation between different stakeholders to get a better common understanding.

Kenneth Marion, chief operating officer of Bonitas, also shared views on the proposed abolishment of brokers.

"Brokers help alleviate some of this confusion by providing an independent evaluation of a person's specific circumstances, both from a financial and healthcare perspective," Marion said.

Marion explained that from a servicing perspective, brokers are "invaluable", as they aid consumers in resolving their queries quickly and efficiently, and help educate them.

Marion believes the abolishment of co-payments is also quite idealistic. This amendment would mean the full cost of healthcare would be covered by schemes.

But Marion explains that in all instances in which co-payments arise, consumers have alternative options to take.

For example, co-payments often apply to elective procedures, or out-of-pocket payments for medicine if generics are available, and if a consumer receives healthcare from a service provider which has not been designated in terms of the rules of the scheme.